Trauma, Teams and Tribes: Vic Brazil at DFTB18

Cite this article as:
Team DFTB. Trauma, Teams and Tribes: Vic Brazil at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20194

Victoria Brazil is a senior staff specialist at the Gold Coast University Hospital. She is a world renowned expert in the role of simulation in medical education.

Thinking FAST, and slow

Cite this article as:
Andrew Tagg. Thinking FAST, and slow, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17324

10-year-old Elliott is brought into your emergency department after falling off his bike. Whilst trying to escape from a gang of bullies he went off-road, left the ground and landed awkwardly. The front wheel twisted and the handlebars hit his belly. He is complaining of pain in the left upper quadrant. He has been treated with intranasal fentanyl and is haemodynamically stable. Your registrar asks if he can do a FAST exam on him.

 

Basics principles of the FAST exam

The Focused Abdominal Sonography for Trauma exam superseded diagnostic peritoneal lavage in the late 1980s as a means of determining significant intra-abdominal free fluid. The actual monicker, FAST, was first used by Royzycki et al back in the mid-90s.

The FAST exam is a rapidly performed test that looks at four specific areas – RIGHT upper quadrant, LEFT upper quadrant, subxiphoid region, and pelvis. The wielder of the probe is looking for free fluid rather than directly looking for solid organ injury.

The 4 traditional FAST views – RUQ, LUQ, subxiphoid and pelvic.

It’s important to remember that the FAST exam came about as a tool to examine haemodynamically UNSTABLE patients in order to determine who needed to go to the operating theatre or needed a critical intervention (such as pericardiocentesis).

According to Rippey and Royce, the sensitivity of FAST in adults ranges from 64-98%. But…

 

What about in kids?

CT is considered the gold standard for the examination of intra-abdominal injury in children but it is not without risk. As clinicians we are reluctant to expose kids to needless radiation and try and act within the ALARA (As Low As Reasonably Possible) principle. With an increased focus on the use of point of care ultrasound throughout paediatrics it can be tempting to translate the adult approach of using the FAST scan, in kids.

A couple of concerns have been raised regarding the use of FAST in children:

 

Not all children with abdominal injuries have free fluid

A number of studies in haemodynamically stable children have found significant solid organ injuries (liver, spleen or kidney lacerations) on CT with normal bedside ultrasound. Whilst 22% of abdominal injuries in adults are not associated with free fluid this rises to a whopping 37% in children.

A 2007 meta-analysis by Holmes et al found an 80% sensitivity for detecting intra-peritoneal fluid via sonography. When the authors only looked at the more methodologically rigorous studies the sensitivity dropped to 66%.

 

The management of solid organ injuries in the paediatric population is different

Nearly all intra-abdominal injuries in children are managed conservatively and so accurate delineation is important. Finding free fluid on sonographic assessment does not mandate them going to theatre, even in the setting of haemodynamic instability. Operative management of hepatic injuries in children has been associated with higher mortality than a conservative approach.

 

So what does this all mean?

CT scanning does have its drawbacks – it involves ionising radiation, IV contrast and is time and money intensive in comparison with the FAST scan. But if ultrasound cannot tell us what we need to know then there is no comparison. A number of studies that have shown a better correlation between CT and US do not use the FAST scan but a modified form or even complete abdominal sonography by qualified sonographers. Given that US is very much an operator-dependent imaging modality it is vital that anyone using it has been trained (and accredited) in its use.

Emergency physicians may think they are amazing at performing a focused abdominal assessment and wield the probe at every given opportunity ‘for practice’. This will skew the accuracy of the test. If the pre-test probability of a positive result is low in the first place then the number of true negatives will, of course, be higher and the accuracy of the test will appear to be higher than it actually is.

In my attempt to trawl through some of the data I have consistently come across the idea that FAST is great because it is so accurate. The only way of knowing this is to look at the studies that compare it with a CT. Just because you do not pick up an injury immediately does not mean that one is not there. For example, in the Soudack et al. paper they described three negative FAST, positive CT cases – a haemo-peritoneum, one splenic laceration, and one hepatic laceration. Because the CT did not show free fluid these did not count as false-negatives!

A positive FAST is helpful but a negative one…not so much.

 

What do I do?

What I am really interested in is the Negative Predictive Value of the test i.e. the chance that if my scan is NEGATIVE there is NO free fluid. Unfortunately, a negative scan, in isolation does not tell me that there is not a significant intra-abdominal injury. In the setting of a worrying mechanism (e.g. handlebar versus spleen) with bruising and tenderness to the left upper quadrant and a NEGATIVE fast I cannot say that the child is okay and send them home. This is the concern that I have. That the test will stop the less astute clinician from thinking.

One has to be very wary when interpreting the literature surrounding FAST scans in paediatrics. All the scan tells you is that there is no free fluid. If the patient is haemodynamically stable and there is suspicion of an intra-abdominal injury then the patient should have a CT.

Haemodynamically stable patients

In the haemodynamically stable patient with an unconcerning physical exam, good quality images on a comprehensive abdominal ultrasound and the ability to serially examine the patient then a CT may not be warranted. A comprehensive abdominal ultrasound is NOT the same as FAST.

One might think that the use of ultrasound might have other benefits but a large study by Holmes et al. in 2017 showed no alteration in the number of CT scans requested, number of patients hospitalized or requiring surgery.

 

Haemodynamically unstable patients

These patients need resuscitation, often with blood products, until they are stable enough to enter the CT scanner/IR suite. A FAST scan is likely to be positive but given that over 90% of intra-abdominal injuries in children are managed without going to theatre it is unlikely to change my management.

Whilst this is clearly not a comprehensive review, any collection of data that has such a wide range of specificity needs to be considered. I could add another 10 studies and they might tighten up my spread but in the largest trials, involving ED physicians we are just not that great.

So the bottom line, when taken in isolation, as I see it is this best case/worst case…

Thanks to Arun Ilancheran and Ross Fisher for pushing me down this rabbit hole.

 

Selected references

Ashrafi A, Heydari F, Kolahdouzan M. The Utility of Ultrasound and Laboratory Data for Predicting Intra-abdominal Injury among Children with Blunt Abdominal Trauma. International Journal of Pediatrics. 2018 Aug 1;6(8):8047-59.

Calder BW, Vogel AM, Zhang J, Mauldin PD, Huang EY, Savoie KB, Santore MT, Tsao K, Ostovar-Kermani TG, Falcone RA, Dassinger MS. Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis. Journal of Trauma and Acute Care Surgery. 2017 Aug 1;83(2):218-24.

Coley BD, Mutabagani KH, Martin LC, Zumberge N, Cooney DR, Caniano DA, Besner GE, Groner JI, Shiels WE. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. Journal of Trauma and Acute Care Surgery. 2000 May 1;48(5):902-6.

Emery KH, McAneney CM, Racadio JM, Johnson ND, Evora DK, Garcia VF. Absent peritoneal fluid on screening trauma ultrasonography in children: a prospective comparison with computed tomography. Journal of pediatric surgery. 2001 Apr 1;36(4):565-9.

Fox JC, Boysen M, Gharahbaghian L, et al. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med 2011; 18:477– 482.

Holmes JF, Brant WE, Bond WF, Sokolove PE, Kuppermann N. Emergency department ultrasonography in the evaluation of hypotensive and normotensive children with blunt abdominal trauma. Journal of pediatric surgery. 2001 Jul 1;36(7):968-73.

Holmes JF, Kelley KM, Wootton-Gorges SL, Utter GH, Abramson LP, Rose JS, Tancredi DJ, Kuppermann N. Effect of abdominal ultrasound on clinical care, outcomes, and resource use among children with blunt torso trauma: a randomized clinical trial. Jama. 2017 Jun 13;317(22):2290-6.

Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. Journal of pediatric surgery. 2007 Sep 1;42(9):1588-94.

Kessler DO. Abdominal Ultrasound for Pediatric Blunt Trauma: FAST Is Not Always Better. Jama. 2017 Jun 13;317(22):2283-5.

Menaker J, Blumberg S, Wisner DH, Dayan PS, Tunik M, Garcia M, Mahajan P, Page K, Monroe D, Borgialli D, Kuppermann N. Use of the focused assessment with sonography for trauma (FAST) examination and its impact on abdominal computed tomography use in hemodynamically stable children with blunt torso trauma. Journal of Trauma and Acute Care Surgery. 2014 Sep 1;77(3):427-32.

Moore C, Liu R. Not so FAST—let’s not abandon the pediatric focused assessment with sonography in trauma yet. Journal of thoracic disease. 2018 Jan;10(1):1.

Murphy R, Ghosh A. The accuracy of abdominal ultrasound in paediatric trauma. Emergency medicine journal: EMJ. 2001 May;18(3):208.

Mutabagani KH, Coley BD, Zumberge N, McCarthy DW, Besner GE, Caniano DA, Cooney DR. Preliminary experience with focused abdominal sonography for trauma (FAST) in children: is it useful?. Journal of pediatric surgery. 1999 Jan 1;34(1):48-54.

Retzlaff T, Hirsch W, Till H, Rolle U. Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma?. Journal of pediatric surgery. 2010 May 1;45(5):912-5.

Rippey JC, Royse AG. Ultrasound in trauma. Best Practice & Research Clinical Anaesthesiology. 2009 Sep 1;23(3):343-62.

Rozycki GS, Ochsner MG, Jaffin JH & Champion HR. Prospective evaluation of surgeons’ use of ultrasound in the evaluation of trauma patients. The Journal of Trauma 1993 Apr; 34(4): 516–526. discussion 26–7.

Scaife ER, Rollins MD, Barnhart DC, Downey EC, Black RE, Meyers RL, Stevens MH, Gordon S, Prince JS, Battaglia D, Fenton SJ. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. Journal of pediatric surgery. 2013 Jun 1;48(6):1377-83.

Schonfeld D, Lee LK. Blunt abdominal trauma in children. Current opinion in pediatrics. 2012 Jun 1;24(3):314-8.

Soudack M, Epelman M, Maor R, Hayari L, Shoshani G, Heyman‐Reiss A, Michaelson M, Gaitini D. Experience with focused abdominal sonography for trauma (FAST) in 313 pediatric patients. Journal of Clinical Ultrasound. 2004 Feb;32(2):53-61.

Soundappan SV, Holland AJ, Cass DT, Lam A. Diagnostic accuracy of surgeon-performed focused abdominal sonography (FAST) in blunt paediatric trauma. Injury. 2005 Aug 1;36(8):970-5.

Suthers SE, Albrecht R, Foley D, Mantor PC. Surgeon-Directed Ultrasound for Trauma is a Predictor of Intra-Abdominal Injury in Children/DISCUSSION. The American surgeon. 2004 Feb 1;70(2):164.

Stabbings in adolescents

Cite this article as:
Tessa Davis. Stabbings in adolescents, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17337

It’s a regular day in your Paeds ED. You’ve just pulled a piece of lego out of a child left nostril; there are two wheezy kids waiting for review to see if they can stretch to two hours; and there is a 2 month old with a rash that you’re currently seeing  – everyone is waiting for you to come up with a clever diagnosis. As you stare at the spots and wait for some inspiration, you hear one of your nursing colleagues call…

Ross Fisher: What surgeons wish you knew from DFTB17

Cite this article as:
Team DFTB. Ross Fisher: What surgeons wish you knew from DFTB17, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16201

This talk was recorded live on the final of DFTB17 in Brisbane. If you missed out in 2017 then why not book your leave for 2018 now. Tickets are on sale for the pre-conference workshops as well as the conference itself at www.dftb18.com.

What more can be said about Ross Fisher that hasn’t already been said? Passionate presenter, good (but not perfect*) surgeon and friend to the stars – in this talk Ross delves into the hidden world of paediatric surgery.

Camille Wu: Testicular Troubles at DFTB17

Cite this article as:
Team DFTB. Camille Wu: Testicular Troubles at DFTB17, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16080

This talk was recorded live on the final of DFTB17 in Brisbane. If you missed out in 2017 then why not book your leave for 2018 now. Tickets are on sale for the pre-conference workshops as well as the conference itself at www.dftb18.com.

Camille Wu is a paediatric surgeon based out of Sydney. Here she talks about those things that make grown men go weak at the knees.

Craig McBride: Minimally Invasive Surgery at DFTB17

Cite this article as:
Team DFTB. Craig McBride: Minimally Invasive Surgery at DFTB17, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16078

This talk was recorded live on the final of DFTB17 in Brisbane. If you missed out in 2017 then why not book your leave for 2018 now. Tickets are on sale for the pre-conference workshops as well as the conference itself at www.dftb18.com.

Craig McBride is a paediatric surgeon at Lady Cilento in Brisbane. Here he talks about how we have moved on from the days of maximally invasive surgery when a barber-surgeon was not judged on the neatness of their sutures but on the sharpness of their blade.

Treadmill Burns

Cite this article as:
Henry Goldstein. Treadmill Burns, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9710

Chase, 3, is brought in by ambulance with his hand wrapped in a towel. His sweaty father – wearing running gear – explains that Chase touched the treadmill whilst Dad was in full flight.

A recently published paper in Burns reviews the epidemiology of treadmill burns;

Goltsman D, Li Z, Connolly S, Meyerowitz-Katz D4, Allan J, Maitz PK Pediatric Treadmill Burns: Assessing the effectiveness of prevention strategies.Burns. 2016 Aug 10. pii: S0305-4179(16)00064-4. doi: 10.1016/j.burns.2016.02.007. [Epub ahead of print]

Goltsman and colleagues reviewed a set of 298 treadmill burns sustained over a 10 year period in NSW, Australia.

Treadmills seem oddly specific, why the focus? Treadmill burns deserve our attention for three reasons;

Prevalence:

Firstly, they are relatively common in the paediatric population, accounting for around 1 in 20 burns.

They’re most common in the 0-5 age group (mean age – 3.8yrs)

More often males; 62%

Treadmill burns are classically small, at less than 1% TBSA.

85% were burns to the hand, with a total of 91% being somewhere on the upper limb.

The lower limb, torso and head & neck each accounted for 4%, 5% and 7% of treadmill burns, respectively.

Pathophysiology:

Secondly, the pathophysiology of treadmill burns is complex.

The basic mechanism is friction. Often, there is also entrapment of limbs, fingers or toes causing extensive and penetrating burns. Blunt trauma may occur when a child falls off the machine.

It is postulated that friction burns in children are particularly severe as their withdrawal reflex is relatively developmentally immature, and their volar epidermis is thinner. In concert, the slow reflex leads to prolonged burn time through more vulnerable skin.

In this data set, 62% of burns were full thickness.

Management:

 Three quarters of the treadmill burns reviewed received no or inadequate first aid. First aid should be provided as per a typical thermal injury with 20 minutes of cool running water.

A significant number require reconstructive surgery; half the patients who sustained a treadmill burn received skin grafts.

An entrapment injury sustained whilst the treadmill was operating was more likely to require grafting.

How might we reduce the prevalence of treadmill burns?

The study data was obtained at a time when legislative changes led to mandatory safety warnings on treadmills. In addition to a multimodal public health campaign, there was a decrease in the annual number of treadmill burns throughout the study period. Yet, the most recent data (from 2014) still sees treadmill burns account for 4% of all paediatric burns.

Goltsman et al., moot the following suggestions to further reduce the risk of treadmill burns in children;

1. Safety devices could make it impossible for a child to start a treadmill;

2. Treadmills could have sensors in the area of danger for friction burns to automatically stop in case a body part gets trapped there;

3. The ‘‘stop’’ mechanism should be easy to reach even after a person has fallen from the treadmill, not just from a standing position; or

4. In order to prevent parents who are using the treadmill from failing to notice children standing or crawling right next to them behind the treadmill, the running treadmill could stop, or play an ‘‘alarm’’ noise if anyone comes close.

This study compliments and earlier review undertaken by Jermijenko et al in 2008;

Jeremijenko L, Mott J, Wallis B, Kimble R. Paediatric treadmill friction injuries. J Paediatr Child Health. 2009 May;45(5):310-2. doi: 10.1111/j.1440-1754.2008.01329.x. Epub 2008 Jun 12.

Pyloric stenosis

Cite this article as:
Erin Sharwood. Pyloric stenosis, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.2768

Key points:

  • Think of pyloric stenosis in a vomiting infant.
  • Only about 1 in 7 cases will have the classic triad of projectile vomiting, visible peristalsis and the palpable “olive”.
  • Hypokalemia suggests several weeks of symptoms.
  • Ultrasound is the most common diagnostic modality, in addition to Hx & Examination.
  • Rehydrate and correct electrolyte disturbances before operative management.

Jackson is a 5-week-old baby brought into the emergency department by his mum Gina. Over the past four days he has had increasing vomiting, and today he seems lethargic. Gina tells you he hasn’t kept anything at all down in the past 24 hours, and has had only one slightly wet nappy since last night.

On examination, Jackson looks pale and mottled. His heart rate is 180 beats per minute, and his respiratory rate is 45. He is afebrile, and his central capillary return is around 3 seconds. You decide to organise an IV cannula for a fluid bolus while continuing to take more history from Gina.

What blood tests would you like to take as you cannulate? What further questions do you have for Mum?

Gina tells you Jackson is her first baby, he was born at term has been fully breast fed. She knows that lots of babies have small vomits after feeding, so wasn’t too concerned initially. The vomit is milky, with no blood or bile. Gina notes that as soon as Jackson vomits he seems hungry and extremely eager to feed again right away. Jackson usually has one or two soft yellow bowel motions a day, and hasn’t had any diarrhoea. Gina doesn’t know of any family history on her side, but isn’t sure about Jackson’s father’s side as they live overseas.

Happily, your cannula goes in beautifully, but yields only enough blood for a venous blood gas. Now what?

While you run through a fluid bolus of 10mL/kg of 0.9% sodium chloride, you take the opportunity to examine Jackson a little further. You find he has a slightly sunken anterior fontanelle. He is sleepy, but sucks vigorously at the pacifier Gina has provided. His abdomen is soft, and you can’t feel any masses in the supine position. There is no respiratory distress, and his lung fields are clear, with dual heart sounds and no murmurs.

What do you expect the gas to show?

As you finish your examination, your blood gas result becomes available. It shows a pH of 7.50, a pCO2 of 50, with a bicarbonate of 38, and a base excess of +5. The electrolytes provided on the gas readout show a sodium of 129, potassium of 3.6, and a chloride of 92.

Jackson has picked up following his fluid bolus, and is now looking for a feed. While keeping maintenance fluids running, you suggest to Gina that offering a breast feed might actually help you confirm the diagnosis. In the meantime, you decide to ask the sonographer if they can help out with an abdominal ultrasound.

As you head back to the room, you run into the surgical registrar and ask them to come and take a look at Jackson. You both note that after the feed, you can see waves of peristalsis across Jackson’s epigastrium going from left to right. You step away just in time to narrowly miss Jackson vomiting forcefully, with milky vomit making it across the cubicle to hit the wall 2 metres away!

The surgical registrar agrees this is very likely pyloric stenosis, and shows you how to palpate his right upper quadrant with Jackson resting prone on her hand. She is suitably impressed by Jackson’s presentation, and happily accepts his care, though she asks you to cancel the ultrasound as she is so confident of the diagnosis. She explains to Gina that Jackson will need surgery to release the muscle between his stomach and duodenum, but first he will need to be rehydrated over night.

Jackson went on to have a laparoscopic pyelomyotomy the following day, with no complications. As they are leaving, they come by to say goodbye, and to let you know it turns out Jackson’s dad also had pyloric stenosis at around about the same age.

What about POCUS?

Sivitz et al established a prospective study assessing the accuracy of POCUS for diagnosis of Pyloric Stenosis; it’s an interesting comparator, but essentially the vast majority of the scans were done by a only one of the participants. It’s also worth noting that the sonographic features become more marked as the stenosis progresses – in the study this meant that all POCUS-negative, sonographer-positive scans were given a free pass. The data suggest that POCUS is suitable as a rule-in test, but is not appropriate for excluding Pyloric Stenosis.

Practice Points

Idiopathic Hypertrophic Pyloric Stenosis typically occurs between 2 and 12 weeks of age, and is around 4-6 times more common in boys, particularly if they are first-born. A family history is often present.

Historically, the diagnosis was made clinically, with a ‘classic triad’ of projectile vomiting, visible peristalsis and a palpable ‘olive’ (the thickened pylorus) in the right upper quadrant at the border of the rectus abdominus muscle. More recently (possibly due to a trend toward earlier presentation to hospital), the ‘olive’ is often not easy to palpate, and ultrasound examination is often employed to confirm the suspected diagnosis. Gotley et al found At least one classic symptom or sign was present in 87% of infants but only 1 in 7 cases had the ‘classic triad’.

Blood gas analysis classically reveals a hypochloraemic metabolic alkalosis. Studies suggest hypokalaemia often doesn’t occur until 3 weeks worth of vomiting. A retrospective study of blood gas results showed that a pH of >7.45, a base excess of >+3, and a chloride of <98 were particularly useful in predicting the diagnosis in babies presenting with vomiting.

Metabolic disturbance needs to be corrected prior to surgery, as this dramatically reduces the risk of intra- and post-operative complications.

 

References

Gotley, LM, Blanch, A, Kimble, R, Frawley, K, and Acworth, JP, “Pyloric stenosis: A retrospective study of an Australian population” Emergency Medicine Australia 21 (2009) 407-413. https://www.ncbi.nlm.nih.gov/pubmed/19840091

Taylor ND, Cass DT, Holland AJ. Infantile hypertrophic pyloric stenosis: has anything changed? J Paediatr Child Health. 2013 Jan;49(1):33-7. doi: 10.1111/jpc.12027. Epub 2012 Dec 2. https://www.ncbi.nlm.nih.gov/pubmed/23198903

Sivitz et al. Evaluation of Hypertrophic Pyloric Stenosis by Paediatric  Emergency Physician Sonography Acad Emerg Med. 2013 Jul;20(7):646-51. doi: 10.1111/acem.12163. Epub 2013 Jun 19. https://www.ncbi.nlm.nih.gov/pubmed/23781883

Oakley EA and Barnett PLJ, “Is acid base determination an accurate predictor of pyloric stenosis?” Journal of Paediatrics and Child Health 36 (2000), 587-589. https://www.ncbi.nlm.nih.gov/pubmed/11115037

DFTB in Dublin – the Workshops

Cite this article as:
Tagg, A. DFTB in Dublin – the Workshops, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/dftb-in-dublin-the-workshops/

Having braved international flights half of the team from DFTB (Andy and Henry) have made it to SMACCDub. For those of you not in the know the Social Media And Critical Care conference is in it’s fourth year now and partly inspired us to start Don’t Forget The Bubbles.  Although the editors regularly chat online this was the first time Henry and I have met in person.

In order to make the most of our time abroad we had both booked into the #SMACCmini paediatric workshop.

SMACCMini

With a line of speakers encompassing the best and brightest from the world of paediatrics (apart from us) we were excited to see what they had to offer. With a variety of lightning 10 minute talks over the course of the morning topics ranged from communication to caring for the critically ill child.

Resuscitation update

Natalie May was our leatherette clad hostess and kicked off the proceedings with an update on the 2015 ILCOR guidelines.  Whilst little has changed in resuscitation of the infant it is the rare resuscitation of the newborn that scares us the most.  Whilst a precipitous delivery in the department may be a rare event, it does happen.  Babies may be born in less than ideal circumstances – on the leather back seat of their husband’s new car, in the toilet (literally) or in the lift up to the birthing suite – but thankfully the need to perform complex interventions is rare. We need to know what to do before help arrives. This short video may help those who are paralysed by fear.

PEM literature update

Tim Horeczko took to the stage next, disguised as an event organizer. Despite technical issues that were out of his control he took us on a whirlwind tour of some paediatric literature that most of us in the room were not aware of.

Approaches to spotting the sick child

The Wonder Woman of Leicester, Rachel Rowlands, then took to the stage (along with her constant companion, Norman the dinosaur) to remind us of the importance of gestalt in spotting the sick child, a theme that would echoed by many speakers throughout the morning.  She took us on a choose-your-own adventure style quest, not to find the treasure, but to save the life of a young boy that had swallowed a button battery.  If you want to know more about the dangers of these deadly discs then take a look at her video.

Spotting sepsis early

Adrian Plunkett talked eloquently on the the use of the NICE traffic light system and other early warning scores to predict sepsis. But really he gave us two key take home points to lock onto:-

  • Be worried if there is a change of state – they are not the same as they were yesterday
  • Be worried if this illness is like no other illness they have ever had

By using these two key questions in the history we might become more alert to the risk of potential deterioration and look for ways to validate our fears – order the extra blood tests, keep the child in for a period of further observation.

Sick neonates are simple

Trish Woods, a neonatologist from WA, reminded us that all neonates want is to be protected.  When they are threatened, be that in the form of imminent airway or breathing difficulty, their physiology wants to return to the womb.  By understanding the transition from safe, warm and comforting intra-uterine life to the harsh outside world we can guide our resuscitation.

Mistakes and pitfalls in critical care

Phil Hyde, who gave an excellent talk about the use of real children during simulation at last years conference urged us to use our fear, not because it leads to the dark side, but to help us step towards the stressful.  We have all been in a resuscitation when there is a palpable sense of half-repressed panic.  Voices are raised and critical instructions missed, mistakes are made. But just as the emotions of the team leader can have a negative impact on the team they can also act to stop the sweating.  By being the slow, smooth voice of calm the team leader can imbue all of the group with the same feeling.

This can be a challenge so there are things we can do to mitigate the internal stress. Cliff  Reid talks of using the high fidelity simulator that is our brain to visualize these high stress scenarios, before they happen.  That is all when and good if you are experienced and have seen a lot of sick kids. But what do you do if you haven’t.  Phil suggests visiting your local PICU and asking questions of doctors and families, stepping towards the fear.  He also suggested using www.spottingthesickchild.com, a free online resource (though you need to register) to make you more comfortable in your assessment of deteriorating infants.

Paediatric ultrasound

The southern hemispheres Wizard of the Wand, Giant of the Gel, Prince of Probes, himself – Casey Parker – demonstrated how easy it is for us all to perform lung ultrasound on children.  In just 8 minutes he reminded us that our clinical exam counts for very nought and that a normal appearing chest x-ray can be deceptive in a child that you think has pneumonia from the history.  Waving the magic wand is easy and can be taught in just four minutes.  It is certainly a skill that I am going to take home to my place of practice.(Ed. I’d just like to give a huge thanks to Casey for encouraging me to write after the first SMACC in Sydney and publishing my very first blog post.)

What paediatric surgeons wished you knew

The esteemed paediatric surgeon, Mr Ross Fisher of p cubed presentations, then took us through some of personal bugbears.  After learning that there is no such thing as a normal bowel habit in a child, a fact that most parents can attest to, to decrying the lack of  proper physical examination prior to imaging he put us in his shoes.  Surgeons have no special ability to rule out appendicitis, but often have the benefit of experience to help determine what else may be going on.

Paediatric toxicology

As we came towards the end of the first half of the morning Nat Thurtle reminded us that children like to put things in their mouths that no normal person would.  Eschewing the usual list of one pill kills she talked about some newer toxins that most of us would not find palatable – e-liquids, laundry detergent pods and synthetic cannabinoids’s. By using the powerful Resus RSI DEAD mnemonic we can have a framework with which to risk stratify and deal with any potential toxic ingestion.

Paediatric trauma

As we were getting ready for our morning coffee Nat May reminded us that paediatric trauma often presents to non-paediatric centres and that we should all be able to recognize and deal with it.  Mechanisms of trauma vary with age from the drunken horse riding antics of teenagers, to younger children who skateboard in front of cars.  Paediatric trauma can be very confronting and how we approach our parents and their families can have a great impact on their long-term outcomes.

The SMACCmini superheroes

Appropriately caffeinated we headed back to the hall for another round of talks.

Excellence in critical care

Adrian Plunkett started off the session on a positive note.  Whilst it is easy to criticise bad practice it is much harder to praise the good.  He urged us to learn from the things we do well.  By actively promoting best practice within your network a culture of positivity and a ‘can-do’ attitude arises.  If you visit the Learning from Excellence website you can learn from others peer-reported episodes of excellence in practice.    Similar to the ‘Awesome and Amazing’ antithesis to the monthly M&M conference we need to let others in the team know they are doing a great job.

Communication: Kids and families

We all have had occasions when we think we have done a great job with our young patients and their families. Roisin McNamara brought us down to earth with a tale of when things that she thought had gone well had been perceived very differently by the family involved.  When harsh words are spoken it is important to have the emotional intelligence not to snap back, not to get angry. Often parents are not angry at you but at the situation but the doctor in front of them is the visible face of a systemic problem.  Parents may feel they are being dismissed as time wasters if time is not spent taking a thorough history and appropriate physical exam before pronouncing that their darling daughter has no medical cause for their symptoms.

Communication: Adolescents

Most of us know how to talk to children but, via the power of video, Thom O’Neill, spoke passionately about an issue we should all know more about- dealing with LGBT adolescents and youths.

Most traditional textbooks of paediatrics have yet to cover the subject and Thom gave us a useful framework to hang a conversation on, starting with recognising the child or youths right to be called what they want and to identify themselves how they want.  We hope to get Thom to write more on this subject for Don’t Forget The Bubbles. 

Resource poor settings

Nat Thurtle returned to the limelight to talk about her time working in resource poor settings.  Those of us that work in the developed world are incredibly lucky to have access to the resources we have. As she told her moving story of almost insurmountable challenges we al stopped and reflected on how lucky we truly are.

Complex kids

After hearing about children that don’t have access to even supplemental oxygen when it is needed Tim Horeczko talked about technology dependent children and their complex needs.  Whilst we are unlikely to encounter a child with a ventricular assist device outside of a quaternary centre we may well be exposed to children with a VP shunt, or a child that suffers from an incurable neuromuscular or mitochondrial defect.  As is nearly always the case in paediatrics – the parents know best, so listen.

Surgical surprises

Ross Fisher then urged us to “Keep Calm and Carry On” when confronted with potential paediatric surgical nightmares. He reminded us time and again that we know how to do the basics – analgesia, fluid resuscitation, investigate – and that there is nothing that we should be afraid of.

Neonatal procedure tips

Having previous told us that looking after sick neonates was easy-peasy, Trish Woods then went n to teach us how. By focusing on the ABC’s of resuscitation she walked us through the neonatal airway and breathing before showing some great slides and giving us all the tools we need to insert an umbilical line. At the time of neonatal resuscitation early vascular access as a means of giving fluids and adrenaline can save a life.  

Intubation tips

This great procedural talk was followed by Tim Horeczko on his top three tips for intubating infants.  We know that critical procedures are rarely performed by paediatricians let alone general emergency physicians but by adding these three things to ones repertoire we should increase our chance of first pass success.

  • Use the shoulder bump
  • Use the jaw thrust
  • Change your position and look high

Ventilation tips

Once we have successfully intubated (and confirmed tube placement with waveform capnography) Phil Hyde talked about ventilation strategies. By using PEEP and low tidal volume breaths (6-8mls/kg) we can adequately ventilate most children titrating to a pH>7.2 and and an SpO2 >92%. Attention to the simple things such as sedation, paralysis and monitoring can make all the difference.

Phil Hyde on the basics of neonatal ventilation

Patient experience

The final session of the day brought home to all of us in the room why we do what we do.  We heard from Emer, a brave 11 year old girl, who had spent 5 days in ICU with tracheitis, of her experience, both in the emergency room and in the unit.  Her clinical care was excellent and could not be faulted but if there was one thing she wanted us all to take away it was ‘Don’t use long medical words’. We doctors assume a common tongue and use medical terminology as a technical shorthand with our colleagues.  We occasionally slip into this mode of talking with patients and their relatives. Emer reminded us to think before we speak.

The organizing committee and all of the faculty did an amazing job of fitting such a wide array of topics in such a short time frame. Never did the audience feel overwhelmed with knowledge and most of us just stopped tweeting and just listened, quietly reflected and were inspired to do better. If you came along to the workshop and took away something that will change the way you treat children (or their parents) then please feel free to comment below.

pablo

 

Breast anomalies

Cite this article as:
Catherine Boorer. Breast anomalies, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.8232

—Most breast lesions in children and adolescents are benign and self limiting. However, it is important not to overlook the impact that abnormal breast development can have on an adolescent’s self-esteem and self-confidence. Here Catherine Boorer (Plastic and Reconstructive Surgeon) discusses the spectrum of presentations.


Polythelia (accessory nipples)

polythelia

  • —Can occur anywhere along the mammary ridge
  • —Occurs in 2% of the population
  • —Treatment is by simple excision

Polymastia

polymastia

  • —Commonly in axilla
  • —Can be associated with polythelia
  • —Treatment is by direct excision +/- liposuction
  • (Note that you can get breast cancer in the accessory parts)

Nipple inversion

nipple inversion

 

  • —This is a normal variant but new onset may represent malignancy or infection
  • —Can be corrected for cosmetic purposes however this may lead to the inability to breast feed

Amastia

  • —Rare
  • —If unilateral – consider Poland’s syndrome
  • —Bilateral with normal pubertal development – normal (bilateral hypomastia– not considered an anomaly)
  • —Bilateral with delayed puberty – work up for ovarian failure (gonadal dysgenesis, androgen insensitivity syndrome, or congenital adrenal hyperplasia; or other disorders including hypothyroidism or poly- cystic ovary syndrome)

Poland’s syndrome

poland

—Occurs in 1 in 20 000 – causes is possibly a vascular accident

—Individuals have a range of anomalies

  • —Amastia
  • —Athelia
  • —Absent chest wall and shoulder girdle muscles
  • —Bony chest wall anomalies
  • —Shortened radius/ulna
  • —Symbrachydactyly

Treatment aims to reconstruct the breast mound (in females) or pectoralis contour (in males). Other procedures may include reconstruction of the anterior axillary fold, nipple reconstruction and contralateral breast lift/reduction. 


Premature breast development

  • —Breast development prior to age of around 7 years
  • —Usually benign and possibly familial
  • —Consider investigating for precocious puberty

Adolescent hypertrophy

hypertrophy

  • —Sustained progressive breast growth >2.5 kg
  • —Multifactorial – familial, related to obesity, hormone imbalances
  • —Significant social, psychological and physical discomfort
  • —In the past, breast reduction was offered at >18 years but this is now offered earlier if significant distress is present
  • If the patient has unilateral hypertrophy, exclude tumours e.g. giant fibroadenoma, lymphoma

Virginal or juvenile breast hypertrophy

juvenile

 

  • —Rare condition where there is extremely rapid breast growth during puberty
  • —Possible end organ sensitivity to gonadal hormones
  • —Can recur immediately after breast reduction
  • —Pharmacological agents are being used to control growth e.g. tamoxifen, danazol, or bromocriptine

Tuberous breasts

tuberous breast

—Congenital anomaly of breast shape

  • —Constricted base
  • —Herniation breast tissue under an enlarged areolar
  • —High IMF
  • —Asymmetry

—Surgery

  • —Breast expansion
  • —Prosthetic augmentation
  • —Areolar reduction
  • —Breast lift

Breast asymmetry

breast asymmetry

—Relatively common presentation at commencement of thelarche

—Likely to be permanent if no catch up growth in the first 1-2 years

—Surgery is indicated for psychosocial distress

  • —Reduction
  • —Breast lift
  • —Augmentation

Breast infections

  • —Abscesses and mastitis can occur at any age
  • —Usually S. Aureus
  • ——Rx antibiotics +/- careful surgical drainage

Breast pain

  • —In the absence of infection or mass usually secondary to hormonal stimulation
  • ——Consider OCP if problematic

Benign breast lumps

  • —>70% fibroadenomas
  • ——Smooth, rubbery, discreet and non-tender (2cm-15cm)
  • ——Diagnose on US

Breast metastases

—Secondary breast metastases more common than primary malignancy

  • —Rhabdomyosarcoma
  • —Lymphoma
  • —Melanoma
  • —Neuroblastoma

Primary breast cancer

  • —Ductal carcinoma, secretory carcinoma, phylloides tumous
  • —Extremely rare (1 in 1m breast cancers occur <20 years)
  • —Usually present as hard, nontender, poorly circumscribed masses
  • —Diagnosis: US, needle or excisional biopsy

BRCA Genes

  • —BRCA 1 & BRCA 2 genes responsible for 7-9% breast cancer
  • —BRCA 1 – 55-65% breast Ca, 39% ovarian Ca risk by age 70
  • —BRCA 2 – 45% breast Ca, 11-17% ovarian Ca risk by age 70

—Screening for BRCA not typically recommended in children of affected families due to lack of consensus of the benefit of medical interventions

—Current guideline: start screening 10 years younger than youngest affected individual but no later than 35 years


Gynaecomastia

gynaec

  • —Increase in the size of male breast tissue
  • —70% boys will develop gynaecomastia in adolescence
  • —75% will have resolution in 2 years
  • —Imbalance in the estrogen/androgen ratios

—Secondary causes

  • —Medications (TCAs, metronidazole, anabolic steroids, ketoconazole, spironolactone….)
  • —Street drugs (ETOH, marijuana)
  • —Herbal products (tea tree oils, lavender oils)
  • —Medical conditions (hypogonadism, liver or kidney disease, Klinefelter syndrome, thyroid disorders)

—Management

  • ——Address underlying conditions
  • —If persistent and causing concern consider surgery
  • —Liposuction
  • —Open excision
  • —Skin resection